Online Photo and Story Release for Starlight Children’s Foundation

Starlight Children’s Foundation is grateful to patients and families who are willing to share their stories. Information about treatment a patient has received, the people they’ve met and their experiences can prove enormously helpful to understanding the positive impact of Starlight programs.

At the same time, the privacy of patients, families and their visitors, as well as the confidentiality of medical and related information, are among our highest priorities. Therefore, permission always is sought from patients or their families or guardians to provide names, photos and information about hospitalization and treatment.

By signing this document, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, and without any further consideration due from Starlight or any third party to me:

  • If signing the consent form for a minor(s):

  • If signing the consent form for yourself: